Vol. 273, Issue 4, H1696-H1698, October 1997
Stimulation of left stellate ganglion prolongs Q-T interval in
patients with palmar hyperhidrosis
Cheuk-Wah
Wong
Division of Neurosurgery, Chang Gung Memorial Hospital, Chang
Gung Medical College, Taipei, Taiwan, Republic of China
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ABSTRACT |
With the advent of transthoracic
video-assisted endoscopic electrocautery of the second and the third
sympathetic ganglia for the treatment of palmar hyperhidrosis, it is
possible to approach the stellate ganglia with ease. To see whether
stimulation of stellate ganglia in humans is similar to the case in
dogs, we stimulated the sympathetic ganglia in 18 palmar hyperhidrosis patients with a coagulation power of 5 W at a frequency of three times
every 2 s. We found that left stellate stimulation prolongs the Q-T
interval and increases the heart rate, whereas right stellate stimulation affects the Q-T interval and heart rate insignificantly, just like the case in dogs in which the left stellate ganglion predominates the right one in determining the Q-T interval. Left stellate stimulation after destruction of the left second and third
ganglia also prolongs the Q-T interval, suggesting that the left
stellate ganglion is more important in determining the Q-T interval.
endoscopy; long Q-T syndrome; sympathectomy
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INTRODUCTION |
THIS STUDY AIMS to see whether stimulation of the left
stellate ganglion prolongs the Q-T interval and increases the heart rate in humans as it does in dogs (5). The study is conducted in
patients with palmar hyperhidrosis characterized by excessive sweating
of the hands and axillae due to excessive activities of the second
(T2) and the third (T3) sympathetic ganglia,
respectively (3). In Taiwan, most of these patients undergo surgery for electrocautery of the T2 and T3 ganglia when
the symptoms disturb their work and other activities such as shaking
hands (2, 6). With the transthoracic video endoscope, it is easy to
approach the T2, T3, and stellate ganglia (10,
11).
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METHODS |
Stimulation method.
Shortly after electrocautery of the T2 ganglion with a coagulation
power of 30 W (electrosurgical unit, Aspen Excalibur, model 60-5200-001; Aspen Labs, Englewood, CO), the temperature of the ipsilateral palm often drops and then rises (10, 11). The drop of the
palm temperature results from stimulation of the T2 ganglion by the initial electric currents from the tip of the coagulation bar. When the ganglion is subsequently destroyed by the
heat of electric currents, the palm temperature rises. When a power of
1-4 W is used to coagulate the T2 ganglion three times in 2 s, there is no obvious change of palm skin temperature. When a
power of 5 W is used to coagulate the T2 ganglion at the
same frequency, it is possible to repeatedly make the palm temperature drop briskly without subsequent rise. This suggests that a coagulation power of 5 W stimulates rather than destroys the T2
ganglion. Because coagulation with more power (W) does not make the
palm skin temperature drop more briskly, sympathetic stimulation was conducted with a coagulation power of 5 W in this study.
Study protocols.
From June 1995 to September 1995, the author performed transthoracic
video-assisted endoscopic electrocautery of bilateral T2
and T3 sympathetic ganglia on 18 palmar hyperhidrosis
patients who gave signed, informed consent. All these patients had
normal electrocardiograms (ECG) 2-5 days before surgery (B; see
Table 1). During the operations, only the limb-lead ECG were recorded because the use of precordial leads would have increased the risks of
wound infection. After the lung was partially collapsed by the
insufflation of CO2 into the
pleural space at a pressure of 12-15 mmHg, the endoscope was
introduced and the surgical field appeared on the video screen (2, 6,
10). The stellate ganglion was found above the upper
border of the first rib extrapleurally (11). The ECG of the patients
were recorded as a control (C). The tip of the coagulation bar was
lightly placed near the stellate ganglion, and the paddle of the
electrosurgical unit was stepped on three times in 2 s. The ECG of the
patients were obtained 30-60 s after the stimulation of the
stellate ganglion (S1). Likewise, the T2 and T3
ganglia were stimulated and the ECG were recorded (S2 and S3,
respectively). The T3 ganglion then was coagulated with a
power of 30 W, and the ECG were recorded 30-60 s afterward (D3).
Likewise, the T2 ganglion was electrocauterized, and the ECG were recorded (D2), usually with a temperature drop followed by a
temperature rise of the ipsilateral palm. The stellate ganglion was
stimulated again, and the ECG were recorded (SS). The lung then was
inflated, the CO2 was allowed to
escape from the pleural cavity through the endoscope, and the wound was
closed in layers. The procedure was repeated on the other side of the
body. At the end of the operation, when the left and right
T2 and T3 ganglia had been electrocauterized,
the ECG were obtained (E). We began the stimulation alternately at the
left (group I) and right (group II) sympathetic ganglia in the 18 consecutive
patients. The follow-up ECG were recorded 5-8 days after the
operation (F).
The corrected Q-T interval (Q-Tc)
was defined by dividing the measured Q-T interval by the square root of
the preceding R-R interval (1). A decreased R-R interval
denotes an increased heart rate. The statistic analyses were performed
according to the Wilcoxon signed rank test unless specified otherwise.
A significant result is indicated by a two-sided test with
P < 0.05 in all cases.
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RESULTS |
Complete anhidrosis of the hands was evident in all 18 patients 1 wk
after the operation, suggesting a complete destruction of the
T2 and T3 ganglia. There was no Horner's
syndrome.
Tables 1 and
2 outline the R-R and the
Q-Tc intervals as well as the
P values of the Wilcoxon signed rank
test. Soon after electrocautery of the bilateral
T2 and T3 sympathetic ganglia, the
Q-Tc intervals of our patients
prolonged significantly (P = 0.0231),
whereas the R-R intervals changed little
(P = 0.1330; see C and E, Tables 1 and
2). However, there is no difference between the
Q-Tc intervals several days before
and after the operation (P = 0.1488;
see B and F, Tables 1 and 2). Figure 1
demonstrates the different slopes of the curves of the mean left R-R
and Q-Tc intervals against the
mean right R-R and Q-Tc intervals
in the various stages of the study.
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Fig. 1.
Mean R-R and corrected Q-T (Q-Tc)
intervals during various stages of study. Curves for mean left R-R
(LR-R), right R-R (RR-R), left
Q-Tc
(LQTc), and right
Q-Tc
(RQTc) intervals are shown for
various stages of study protocol: B, 2-5 days before operation; C,
control; S1, stimulation of stellate ganglion; S2 and S3, stimulation
of T2 and T3 ganglia, respectively; D3 and D2,
electrocautery of T3 and T2 ganglia,
respectively; SS, stimulation of stellate ganglion after destruction of
T2 and T3 ganglia; E, end of operation; F,
follow-up 5-8 days after operation.
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The P values of the control R-R and
Q-Tc intervals are 0.1853 and
0.3772 between group I and
group II patients, respectively (see
C, Tables 1 and 2, respectively; Mann-Whitney
U-test). After electrocautery of
bilateral T2 and T3 sympathetic ganglia, the
P values of the R-R and
Q-Tc intervals are 0.7723 and
0.2472 between group I and
group II patients, respectively (see
E, Tables 1 and 2; Mann-Whitney U-
test).
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DISCUSSION |
Most patients with palmar hyperhidrosis have normal
Q-Tc intervals before and after
the operation (see B and F, Tables 1 and 2). The
P values of the Mann-Whitney
U-test suggest the absence of sampling
bias in R-R and Q-T intervals between group
I and group II
patients.
Our data demonstrate that, in humans, stimulation of the left stellate
ganglion with intact right sympathetic trunk significantly prolongs the
Q-Tc interval and increases the
heart rate (see S1, Table 1), whereas stimulation of the right stellate
ganglion with intact left sympathetic trunk insignificantly affects the Q-Tc interval and the heart rate
(see S1, Table 2). The finding that left stellate stimulation increases
the heart rate (Fig. 1) is in agreement with certain dog studies (5)
but at variance with others (7, 8). Our data suggest that the left
sympathetic trunk predominates the right one in determining the heart
rate and the Q-T interval in humans. In group
I patients, there are wide variations in the heart
rates before stellate stimulation and in the decrements of R-R
intervals afterward (see C and S1, Table 1), especially for those with
slower control heart rates (see C, Table 1, for
patients 2, 8, 10, and
18).
Because cardiac sympathetic fibers originate from the superior, middle,
and inferior (stellate) cervical ganglia in conjunction with the first
four or five thoracic sympathetic ganglia, one may expect shortened
Q-Tc intervals after destruction
of the left T2 and T3 sympathetic ganglia. This
is not the case in our patients, whose
Q-Tc intervals change little
before and after the operation (P = 0.1488; see B, F, Tables 1 and 2), except that the
Q-Tc intervals prolong
significantly soon after electrocautery of the bilateral T2
and T3 sympathetic ganglia
(P = 0.0231; see C and E, Tables 1 and
2; Fig. 1). It is possible that the spread of the electric currents
while electrocauterizing the left T2 and T3
ganglia actually stimulates the left stellate ganglion and that the
effect of the left stellate stimulation lasts at the end of the
operation (see E, Tables 1 and 2) and fades in a few days (see F,
Tables 1 and 2; Fig. 1). These data are consistent with the notion that
the left stellate ganglion is more important than the left
T2 and T3 ganglia in determining Q-T interval
(9). Indeed, left stellate stimulation after destruction of the left T2 and T3 ganglia prolongs the
Q-Tc interval
(P = 0.0077; see SS, Table 1).
The finding that the left and the right stellate ganglion exert
opposing effects on the Q-T interval is supported by prolongation of
the Q-T intervals in a patient with destruction of the right sympathetic trunk after radical neck dissection (4) and in dogs with
right stellectomy (5, 9). It is possible that the effects of right
stellate stimulation are not strong enough to overcome those of the
predominant left stellate ganglion, whereas destruction of the right
sympathetic trunk unmasks the effects of the predominant left
sympathetic trunk.
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ACKNOWLEDGEMENTS |
Dr. Ting-Chang Chang is acknowledged for advice on statistics and
processing of data.
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FOOTNOTES |
Present address and address for reprint requests: C.-W. Wong, Flat B,
4/F, Chiat Hing Building, 213-221 Yu Chau St., Kowloon, Hong Kong.
Received 6 August 1996; accepted in final form 16 June 1997.
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AJP Heart Circ Physiol 273(4):H1696-H1698
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Copyright © 1997 the American Physiological Society
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